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          <h1 class="post-title" itemprop="name headline">龋病10——橡皮障</h1>
        

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        <p>8.其它问题<br>橡皮障<br>说明书没找到，直接看视频吧。<br><a target="_blank" rel="noopener" href="http://v.qq.com/x/page/c0738m43urw.html">http://v.qq.com/x/page/c0738m43urw.html</a><br>optiDam<br>看视频笔记：无需打孔，直接剪。分前牙/前磨牙专用款，一侧预设6个牙位。分上下颌，上颌有个+号，下颌为-号。磨牙专用款不分上下颌。<br>由橡皮障和面弓组成，面弓一端为上方，对着鼻孔。凹向部分贴合面部。上方橡皮障有+号，对着上中切牙。下方有-号，对着下颌切牙。<br>先把橡皮障挂于下颌正中及两侧最突出的三个齿上。先挂下颌正中，再挂左右两侧最突点，最后是其余的齿。挂住即可，不用覆盖过多的橡皮障架。<br>在突起2/3处剪去相应牙位的橡皮突起，不能齐根剪，剪刀应与牙位对应的橡皮障边缘垂直，不能平行去剪。(看视频，意思是只能从颊舌侧去剪，不能近远中向去剪，怕剪到其它牙位）。<br>前牙/前磨牙<br>将橡皮障放入牙位，最后在两侧最远中使用软楔。前牙橡皮障不用使用橡皮障夹。<br>使用排龈刀或塑形器等钝性器械将橡皮障边缘翻入龈沟处。安放完成。<br>磨牙<br>需要使用橡皮障夹，为通用款，无需选择。<br>安放好后弓部在暴露牙位的远中端。<br>两侧的孔是钳子夹持的部位，外周边缘成为喙部。<br>撑开橡皮障，将夹穿过橡皮障孔，将夹底部通过障布，通过后进行方位确认。弓部暴露于医生视野且朝向远中，两侧孔也暴露在视野里。翻转后见夹子底部完全位于内侧。将装好夹子的橡皮障放入口内，专用钳子撑开橡皮障夹。将夹子撑开到最大，安置到患牙颈部。安放初步完成。下一步用钝性器械（视频是用粘充）将障布翻到夹子的喙部以下，让夹子的全部边缘暴露于口腔。使用楔线让障布进入近中邻间隙，并将软楔固位于此处。检查，如果夹子内部橡皮障未完全隔离牙龈，用钳子将夹子重新在原位撑开一次即可。<br>看看文献<br>①R.F.Kaptan, F.Haznedaroglu, M.B.Kayahan, et al. An Investigation of Current Endodontic Practice in Turkey. The Scientific World Journal, 2012, 1-6.<br>土耳其牙髓治疗情况的调查。<br>方法是对参加第16届土耳其牙医协会的1400名牙医进行问卷调查。回复率43%。92%的被调查者声称没有使用过橡皮障。最常用的测量根管长度的方法是拍X片（p&lt;0.05）。术后修复方式最常用的是树脂充填。<br>只有2%的人宣称他们总是使用橡皮障进行根管治疗，91.9%的人宣称从未使用过橡皮障。使用率与医生年资之间没有关系(p=0.076)。<br>（中国的情况也差不多吧）<br>根据SES的指南，RCT治疗过程应当在牙齿被橡皮障隔离的情况下进行，这主要是为了防止牙髓再感染以及预防器械误吞误咽。在土耳其的牙科学校都要教学生使用橡皮障（我们当年可没教，只是见老师示范了一次）。不使用橡皮障的原因，是治疗时间消耗，没有合适的器械可用，使用成本昂贵以及患者不愿意用等。<br>(搜了一下那个指南，看看）<br>②Mohammad Ahmad AI-Omari, Ziad Nawaf AI-Dwairi. Compliance with infection control Programs in Private Dental Clinics in Jordan. Journal of Dental Education, June 2005, 69(6):693-698.<br>在2004年对120位牙医进行问卷调查，应答率91.66%。大约77位牙医经常询问他们的患者医疗史，36%注射了乙肝疫苗，81.8%在治疗中使用手套并每位患者都更换，54.5%的患者在治疗中使用并且每位患者更换口罩。只有41.8%的医生看每位患者都换机头。只有18%（20/110）的医师在把印模送加工厂以前将印模消毒。14%的医师在治疗中使用橡皮障。<br>（使用橡皮障的情况比土耳其好一点，其它就不评价了）<br>③Gregg H Gilbert, Joseph L Riley, Paul D Eleazer, et al. Discordance between presumed standard of care and actual clinical practice:the example of rubber dam use during root canal treatment in the National Dental Practice-Based Research Network. BMJ Open 2015:5:e009779.<br>研究目的：(1)定量研究牙医对使用橡皮障的态度；(2)检验牙医的态度会影响牙医使用橡皮障的程度的假设。<br>研究对象：1490位在National Dental Practice-Based Research Network中的牙医。(这个网络有个网站，专业人士可以申请加入的，填一个调查问卷即可。)<br>研究方法：问卷调查。<br>研究结果：五个态度因素（橡皮障的效果，不方便性/时间消耗，移动位置(ease of placement)，与其它隔离措施的效果比较，患者因素）被识别出来，被访牙医根据其态度被分为4个群组，每个因素和群组对橡皮障的使用有着独立和强烈的影响。<br>结论：全科牙医对橡皮障的态度差别很大。相信橡皮障使用没有效果，不方便，消耗时间，放置不容易或者被患者因素影响的牙医，使用橡皮障的比例较低。这些态度解释了治疗标准与治疗实践之间的不一致性。<br>只有47%的牙医报告他们在根管治疗时总是使用橡皮障。有时使用棉卷隔湿的比例是47%，总是使用棉卷的比例是12%。Isolite的使用比例是8%。<br>搜了一下，Isolite长这样<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0038-qb10-xpz/01.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0038-qb10-xpz/02.jpg"><br>还有3%用其它隔离方法。只有5%没有用任何隔离方法。<br>(美国是比别的地方好一些，不过总是使用橡皮障的比例也才47%，不到一半。参考文献里有很多信息，找找看。）<br>④Po-Yen Lin, Sbib-Hao Huang, Hong-Ji Cbang, et al.The Effect of Rubber Dam Usage on the Survival Rate of Teeth Receiving Initial Root Canal Treatment: A Nationwide Population-based Study. JOE,November 2014,40(11):1733-1737.<br>研究目的：使用居于全国(应该是台湾地区）范围的人群的数据库调查使用橡皮障是否影响初次根管治疗的患牙生存率。<br>方法：在2005年-2011年期间接受初次根管治疗并且截止2011年仍在跟踪的517234颗患牙被纳入研究，用统计学方法(Univariate and multivariate Cox proportional hazards models，不知道是啥）进行分析。<br>结果：在517234颗患牙中，29219颗被拔除，患牙生存率94.4%。在术后3.43年使用橡皮障的初次根管治疗患牙留存率约90.3%，比不使用橡皮障的根管治疗的患牙留存率88.8%要高（p&lt;0.0001）。在调整了年龄，性别，牙齿类型，医疗机构水平(level)，根管治疗后牙齿检查频率，以及系统性疾病等因素后，使用橡皮障的患牙拔除率仍然显著低于不使用橡皮障（危险比率=0.81,95%可信区间,0.79-0.84）。<br>结论：在初次根管治疗中使用橡皮障能显著提高患牙的留存率。本研究结果支持使用橡皮障能改进根管治疗。<br>橡皮障从1864年引入牙科实践，使用橡皮障的3个优点是：促进感染控制，患者保护，提高治疗效果。在台湾橡皮障的使用率仅16.5%。<br>（台湾的调查结果，样本量蛮大的，数据应该比较可靠。文章还提到了橡皮障的历史，看看参考文献。）<br>查到的文献大多是对牙医使用橡皮障的态度的调查的。根管治疗使用橡皮障很有必要，我以前当然也知道有橡皮障这东西，但老师不用，同事不用，自己当然也就不用了。我自己还是学牙体牙髓的，惭愧啊。以后尽量用上吧。至于龋病充填，看情况吧。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>

      
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